Provider Demographics
NPI:1386144699
Name:MCLEAN, CHARLES DYLAN
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DYLAN
Last Name:MCLEAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PEARL AVE N
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-4632
Mailing Address - Country:US
Mailing Address - Phone:912-331-0846
Mailing Address - Fax:678-792-4894
Practice Address - Street 1:118 PEARL AVE N
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-4632
Practice Address - Country:US
Practice Address - Phone:912-331-0846
Practice Address - Fax:678-792-4894
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002651235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist